ASSESSMENT Subjective:

DIAGNOSIS

PLANNING Short Term Goal: After 8 hours of nursing intervention, the patient will be able to demonstrate behaviors to improve circulation. Long Term Goal: After 3 days of nursing intervention, the patient will be able to demonstrate increased perfusion as appropriate.

INTERVENTION Independent: 1. Monitor signs.

RATIONALE

EVALUATION Short Term Goal:

Ineffective tissue perfusion related Nanghihina pa ang to decreased katawan ko, as hemoglobin verbalized by the concentration in patient. the blood. Objective: BP: 100/70 PR: 65 bpm RR: 19bpm Hgb: 117 g/L Hct: 0.34% Pallor Capillary refill time: >3 seconds

vital 1. To observe for After 8 hours of improvement of nursing intervention, patients condition. the patient was able to demonstrate 2. Elevate head of 2. To promote behaviors to bed. circulation. improve circulation. 3. Provide calm and 3. To promote comfort restful environment. and to decrease tissue Long Term Goal: oxygen demand. After 3 days of 4. Instruct patient to nursing intervention, avoid strenuous 4. to decrease cardiac the patient was able activities. workload and tissue to demonstrate oxygen demand. increased perfusion 5. Encourage light as appropriate. ambulation as 5. To enhance venous tolerated. return. 6. Encourage use of relaxation 6. To decrease tension techniques. and anxiety level. 7. Discourage sitting/standing for 7. To improve and long periods, facilitate good wearing constrictive circulation. clothing, and crossing of legs. 8. Promote adequate

bed rest. 8. To provide wellness. Dependent: 9. Administer medications as ordered. 9. To treat underlying cause. 10. Regulate IVF as ordered. 10. To maintain hydration. Collaborative: 11. Monitor lab studies (Hgb, Hct, RBC, WBC, platelet 11. To establish blood count). replacement needs and to monitor the effectiveness of therapy.

ASSESSMENT Subjective:

DIAGNOSIS to

PLANNING Short Term Goal:

INTERVENTION Independent:

RATIONALE

EVALUATION Short Term Goal:

Hyperthermia related Nilalagnat ung inappropriate anak ko ilang araw clotting factor na. as verbalized by evidence the patients mother decrease platelet count. Objective: Temp of 37.8C Flushed skin Skin warm to touch

After 8 hours of Monitor vital signs. as nursing by intervention, the in patient will be at a normal temperature. Provide calm and restful environment. Long Term Goal: After 3 days of nursing intervention, the patient will be able to maintain normal body temperature. Provide TSB

To observe for After 8 hours of improvement of nursing intervention, patients condition. the patients temperature is To promote comfort normalized goal was and to decrease tissue met. oxygen demand.

To maintain normal Long Term Goal: body temperature using non pharmacological After 3 days of Dependent: intervention. nursing intervention, the patient was able Administer to maintain normal medications like To maintain normal body temperature antipyretics such as body temperature using goal was met. tempra as ordered pharmacological by the physician. intervention in collaboration with the physician Regulate IVF as ordered. To maintain proper fluid and electrolytes Collaborative: Monitor lab studies (Hgb, Hct, RBC, To monitor platelet WBC, platelet count and have a proper count). intervention INTERVENTION RATIONALE

ASSESSMENT

DIAGNOSIS

PLANNING

EVALUATION

Subjective: nagkakapasa na ung braso ko dahil sa palaging pagkuha ng dugo sakin. as verbalized by the patient. Objective: Pallor Hematoma on upper extremeties Weakness impaired Circulation

Impaired tissue integrity related to mechanical and chemical factor of Iv infusion and blood test. Secondary to hematoma as evidence by collection of blood on the upper extremeties.

Short Term Goal: After 4 hours of nursing interventions patrient will demonstrate behavior to refuce hematoma

Independent: Monitor changes VS

Short Term Goal:

and To observe progress of After 4 hours of vital signs nursing intervention, the patient was able Provide comfortable To ease patients to demonstrate environment anxiety and to help the behavior to refuce patient recover faster hematoma goal was for proper hygience of met. the patient Provide safety by Long Term Goal: Long Term Goal: placing pillows at To avoid patient from the side of the bed injury After 2 weeks of After 2 weeks of nursing intervention, nursing Assess skin/tissues, presence of interventions bony prominences, To comparative hematoma was presence of pressure areas and baseline reduced goal was hematoma will be wounds met reduce. Dependent: Administer medication as To promote proper prescribed by the circulation through physician. pharmacological intervention. Collaborative: Mobitor laboratory studies To changes indicative of healing or infection complications.